Questions raised over use of misoprostol to prevent postpartum haemorrhage in poor countries

The World Health Organization should reconsider its approval of misoprostol to prevent postpartum haemorrhaging in poorer countries, says a review of the evidence.1

The review concluded that the evidence to support the use of misoprostol in low and middle income countries in home and community settings where parenteral uterotonics were not available was “at best weak and inconclusive.”

Most maternal deaths relating to pregnancy and childbirth occur in lower income countries, and a quarter of deaths are associated with postpartum haemorrhage, defined as blood loss of more than 500 mL after a vaginal delivery.2

Anaemia is the main risk factor for postpartum haemorrhage and can be treated easily if diagnosed. But in lower income countries without antenatal screening for anaemia WHO guidelines recommend that skilled birth attendants perform active management of the third stage of labour. This consists of three interventions: prophylactic administration of a uterotonic drug, where oxytocin is the drug of choice followed by ergometrine/methylergometrine; early cord clamping and cutting; and controlled cord traction.3